Even in cities, Indigenous midwifery is challenging for many expectant parents to access. While expecting parents in urban areas don’t usually have to travel to give birth, they still commonly encounter discrimination and negligence in the medical system, as well as ignorance of Indigenous practices and traditions around pregnancy. It’s rare to have an experience like that of Salia Joseph, a member of the Squamish Nation who lives in Vancouver and was cared for in her first pregnancy by Keisha Amanda Charnley, a midwife from the nearby Katzie First Nation. When Joseph wanted to do winter bathing, a Salish cultural practice of cleansing oneself in the glacial waters of a mountain stream, Joseph says Charnley understood why it was important and supplied her with information from Salish knowledge keepers and a peer-reviewed article on cold-water immersion in pregnancy that assured her that it was safe. “She had this wealth of knowledge for me to draw on in my pregnancy,” says Joseph.

As far as Charnley is aware, she is one of only four practising Indigenous midwives in Vancouver, despite it being a major city with the third-largest urban population of Indigenous people in Canada. “It’s really hard to be the only one in this area,” Charnley told me. “And also, my belief is that we need to move away from the pan-Indigenizing that has been happening in the health care system too. I’m not going to be the midwife for everyone—we need midwives from every community, so that families who are having babies can have someone who knows their culture.”

During my pregnancy, my non-Indigenous midwifery team asked if there were elements of my Cree culture that I wanted to incorporate into my care. I struggled to answer. Historically, birth was communal, drawing on generational knowledge, shared traditions, and community support. Even if I had known what to ask for, there was no one who could provide it to me.

That absence of knowledge and care is something the federal government acknowledged in 2017, when then health minister Jane Philpott pledged to “return the cries of birth” to Indigenous communities. She announced an investment of $6 million for Indigenous midwifery over five years. Currently, Indigenous midwifery receives just over $16 million annually in federal funding—an investment divided across hundreds of Metis, Inuit, and First Nations communities, with no commitment for most of the funding beyond 2029. Funding is already the biggest barrier to Indigenous midwifery. Prime Minister Mark Carney’s 2025 budget acknowledged: “Many people [in the North] must leave their communities to access specialized care or to give birth.” While the federal government announced that a “comprehensive assessment” will be conducted, it made no funding commitments—while proposing almost $2.3 billion cut from federal Indigenous services by 2030.

JUST A FEW generations ago, Indigenous midwives were ubiquitous. My own great-great-grandmother, Sarah Greyeyes, was a midwife. The last baby she caught on Muskeg Lake was in 1948, the year before she died. After that, babies born there were no longer delivered with a midwife; they were usually born at hospitals, such as the nearby North Battleford Indian Hospital. Like many other Indian hospitals, it was understaffed and underfunded; tuberculosis was rampant, as was discrimination. Nonetheless, H. C. Norquay, the government physician for Battleford, was mystified by the preference of local First Nations to care for one another at home over “the comforts which an institution would provide,” and in 1923, he urged authorities to “break up this custom among the Indians,” according to a journal article by historian Maureen Lux. This patronizing attitude persists: though there is little evidence for the health and safety benefits of evacuating low-risk pregnancies, and tremendous social and financial costs, this remains federal policy.

Birth is a singular event, which for most Canadians typically follows months of sustained, attentive prenatal care. Because so many Indigenous parents-to-be are evacuated to give birth and traditional midwifery has been actively discouraged, many can’t access care in their own communities—and are less likely to receive prenatal ultrasounds or regular appointments than non-Indigenous parents. Heartbreaking inequities persist after birth: infant mortality rates are more than twice as high among First Nations people and nearly four times as high among Inuit. Mortality rates among Indigenous birthers are also twice as high, and Indigenous parents are almost twice as likely to experience postpartum depression. A 2017 study found that rates of sudden infant death syndrome—SIDS—are more than seven times higher among First Nations and Inuit populations compared to non-Indigenous Canadians.

In addition, Indigenous people frequently encounter discrimination in health care. “In Plain Sight,” a 2020 report on Indigenous experiences of racism in the BC health care system, quoted an obstetrician who recalled an anesthesiologist “manhandling” and shouting at a labouring patient before later saying, “People like her should be sterilized.” In fact, forced sterilizations were done routinely on Indigenous women until the mid-1970s, though that crime is not confined to the past. A class action lawsuit alleging forcible sterilization was filed in Saskatchewan in 2017, with over 100 women later coming forward. Earlier this year, Newfoundland and Labrador publication The Independent reported that more than twenty patients had filed complaints against an obstetrician gynecologist, including one from an Inuk mother who alleged her fallopian tubes were removed without consent.

Such discriminatory care can be deadly. In September 2020, a mother named Joyce Echaquan was hospitalized in Quebec with stomach pain. In agony, Echaquan livestreamed, via Facebook, hospital staff belittling her and mocking her pain shortly before her death from pulmonary edema. In the wake of her death, the federal government announced it would address anti-Indigenous racism in health care—including through increased funding for Indigenous midwifery and doula care.

Canada did not regulate midwifery until the very end of the twentieth century, when Ontario became the first province to register midwives in 1994—one of the last industrialized nations to do so. (Newfoundland, which did introduce a midwifery act in 1920, gradually stopped training and licensing midwives after it joined Canada in 1949.) Prior to these changes, midwifery was a legal grey area. This restriction contributed to a critical shortage of maternity care that has been worsening for decades. Outside of urban areas, a shortage of obstetricians puts parents and babies at risk. Many birthing parents simply have no accessible care in their community, whether or not they are Indigenous.

Laura Mayer is the executive director of NCIM, which works in partnership with the Canadian Association of Midwives to support midwifery around the country. A lawyer by training, Mayer had three babies under the care of Indigenous midwives. “Being able to give birth in the place of your choosing is a very empowering thing. It kind of sets the tone of your own personal sovereignty as an Indigenous person.” Her two younger children were born in her partner’s community. “There’s something really amazing about putting Nipissing First Nation as their place of birth.” Mayer says that Canada would require 8,000 midwives to meet demand. “We have around 2,100,” she says.

The first cohort of midwives trained through Canadian university programs graduated less than thirty years ago. Today, around one in eight babies born in Canada is delivered by a midwife, according to the Canadian Association of Midwives. But in Nunavik, Quebec, Inuulitsivik Health Centre’s midwifery service has been delivering babies in community since 1986, making it the longest-running modern midwifery practice in Canada. In 1996 and 2004, they established two more midwifery practices in the Hudson Coast region. While high-risk patients are evacuated to southern hospitals, around 86 percent of Inuit give birth in community; the rest are evacuated, often to Montreal.

Years of data collected by Inuulitsivik reveals superior outcomes in certain areas for these birthers and their babies compared to nearby Nunavut. Each of those evacuations can cost up to $31,794 just for transportation, according to a recent literature review. While the total number of birth evacuations is hard to estimate, it is almost certainly thousands of births every year; a 2022 study found that from just one Nunavut region in 2011, there were 232 birth evacuations to Manitoba, representing 80 percent of babies born to residents that year.

Because midwives are health care professionals, like nurses and dentists, each province has a regulatory body to keep track of those licensed to practise, a mechanism which includes upholding standards for education, experience, and professional ethics. While this system keeps patients safe, it also creates barriers for aspiring practitioners, who must jump through hoops that permit only so many people to pass through at a time. Just six post-secondary programs exist for midwifery training, and they collectively have space for around 150 students each year. In comparison, more than 3,000 students enrol in Canadian medical schools each year. There are currently no post-secondary midwifery programs located north of Calgary—another barrier for aspiring midwives from Northern communities.

Inuulitsivik has a midwife-training program, and since 2008, Quebec’s midwifery regulator has recognized its graduates as licensed practitioners, equivalent to those educated in Canadian post-secondary institutions. The Cree regional health and social services board for Eeyou Istchee in northern Quebec also began training its own midwives in 2024. Tsi Nón:we Ionnakerátstha, the maternal and child health centre on Six Nations of the Grand River, trains midwives, who can practise under a unique exemption clause in Ontario which allows Indigenous midwives to be regulated by their own communities. But so far, only Ontario and Quebec recognize Indigenous midwives trained in community.

In response to this lack of accessible training, NCIM has created an Indigenous midwifery education framework, which began seeking participants in 2021. “There are lots of core competencies for midwives globally,” says Couchie, “but for Indigenous midwives, we also looked at language, medicines, land-based knowledge, all that stuff.” The diversity of Indigenous cultures required taking a high-level approach, she adds. “So, for instance, we’ll say: Acknowledge the baby in the way that your community acknowledges the baby. Learn the medicines in your territory. All the things that non-Native midwives may never think to include.”

The idea for the framework emerged during the pandemic, which ushered in a new era of virtual learning. “We thought: Why don’t we just train people who are doing this kind of thing at the community level?” says Couchie, who helped develop the framework. “I’m going to be teaching them clinical skills, we’ll meet online around every week, and slowly but surely, we’re going to turn them into midwives.”

Each is training at their own pace, in their community, through partnerships with clinics and practising midwives, and gathering annually for a land-based training hosted by NCIM. The flexibility in location and scheduling is critical for aspiring midwives like Nilak Ironhawk-Tommy, a member of Cowichan Tribes in BC who is training on Vancouver Island. She is able to stay close to home and lean on family for support and child care for her son. Ironhawk-Tommy says the structure allows trainees to keep their people and culture at the centre of their training, instead of “being taught colonial ways of being, and then trying to figure out how we’re gonna fit our ways of being into it,” she says. “We’re doing the opposite.”

AS PROVINCES AND territories introduced midwifery legislation one by one—ending with Prince Edward Island in 2022—inroads were made across the country to establish practices, many in communities that desperately needed maternity care. But progress has not been linear, and in some regions, it can seem as though things are going backward.

Lesley Paulette, a member of Tthebatthie Denesųłiné Nation (formerly known as Smith’s Landing First Nation) in Alberta, was one of the first midwives registered in the province, in 1998. For years, Paulette, who worked across the border, in Fort Smith, Northwest Territories, advocated for midwifery legislation in the territory. She established the territory’s first midwifery practice, in Fort Smith, in 2005, shortly after legislation went into effect. Nine years later, she advised on the establishment of a second program, in Hay River. Both communities, Paulette says, lacked physician birth services and had grassroots support for midwifery. “Since then, no new community-based midwifery practices have been established in the territory,” she says. “In twenty years, we got midwifery practices into two communities.”

A few years ago, the expansion of midwifery services looked promising. But last year, in the wake of the costs of the 2022 flooding and 2023 wildfires, the government announced it was cutting four midwifery positions meant to service Yellowknife, Behchokǫ̀, Dettah, and Ndılǫ—the equivalent of nearly a third of all midwifery positions in the territory. The positions had been challenging to fill, according to the territorial government; Paulette feels the recruitment process needs to emphasize a lasting commitment to midwives in order to attract people ready to put down roots in the community. “Health systems still hesitate to really embrace the midwifery model of care,” she says. “They don’t understand the value of it, or they’re trying to figure out how to make space for it in a system that has traditionally favoured other models of care.”

“Births are the number one reason for hospital admissions in Canada,” says Nathalie Pambrun, a Metis midwife based in Victoria. “Midwifery could really create cost savings, if you have birthplace options. The right provider, in the right place, at the right time.” Since 2022, Pambrun and Melanie Mason have operated South Island Indigenous Midwifery Service, the only Indigenous midwifery practice on Vancouver Island. It has struggled to operate on a series of short-term contracts from Island Health, which receives its funding from the BC Ministry of Health. After holding a protest on the grounds of the provincial legislature in June in response to their contract expiring without renewal, Mason says, they were told by the ministry that the contract had in fact been extended for another six months—but only for a single position, far short of the four service contracts they had requested. (By email, the BC Ministry of Health said it does not currently fund any other Indigenous midwifery service contracts in the province but provides $2.5 million in ongoing renewable funding to the provincial midwifery association to support Indigenous midwifery.)